Eye Therapy with Dr. Gerald Komarnicky
Show Notes:
One of the most common and most unpleasant symptoms of a concussion injury is the damage to one's ocular motor function. If you are struggling with your vision, you are probably struggling to live a normal life. That’s why we have Dr. Gerald Komarnicky with us on the show today; a highly distinguished optometrist who deals regularly with patients who are suffering from concussion injuries. Gerry explains how our vision works, the types of visual difficulties that people experience with a concussion injury, and how he helps concussion survivors regain their normal motor functioning and therefore regain their lives. We discuss in detail how the C-Rod, the tool he developed, should be used, how long you can expect to use it for, and how you are likely to feel when you start using it. Concussion is a life-long injury, but it doesn't haven’t to cause life-long distress or suffering.
Key Points From This Episode:
● Hear about Gerry’s impressive professional background.
● Visual evoked potentials (VEP) and how this relates to concussion injury.
● The tool that Gerry developed to help people recover from concussion injury.
● Tests that Gerry does to show people the extent of their injury.
● Astonishing facts about how much of your brain activity is attributed to visual processing and integration.
● Gerry explains what our three oculomotor skills are.
● Resolving visual discomfort is life changing for concussion survivors.
● The importance of doing eye exercises correctly; the little details make a big difference.
● Vertical deviation; what it is and why it is so commonly overlooked.
● How the regulatory bodies for health professionals function.
● Problems with the clinics that claim they are accredited.
● Evidence-based treatments versus evidence-informed treatments.
● The multifaceted device that is the C-Rod, and how it can be used specifically to help with concussion recovery.
● Eye functions that are diminished when a person suffers a concussion.
● Similarities between binocular vision disorder and concussion disorders.
● The length of time you can expect to need to use the C-Rod before your vision is back to normal.
● Cellular level impacts of a concussion.
● How concussion injury management has changed over the years.
● Tiredness is expected when using the C-Rod; “vision is an energy expensive activity.”
● Concussion is a life-long injury, but it can be managed in a way that allows you to have a normal life.
Get started with your own eye therapy today:
Transcript - Click to Read
[INTRO]
[00:00:05] BP: Hi. I’m your host, Bella Paige. Welcome to the Post Concussion Podcast; all about life after experiencing a concussion. Help us make the invisible injury become visible.
[DISCLAIMER]
[00:00:22] BP: The Post Concussion Podcast is strictly an information podcast about concussions and post-concussion syndrome. It does not provide, nor substitute for professional medical advice, diagnosis or treatment. Always seek the advice of your physician, or another qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice, or delay in seeking it because of something you have heard on this podcast. The opinions expressed in this podcast are simply intended to spark discussion about concussions and post-concussion syndrome.
[EPISODE]
[00:01:00] BP: Welcome to today's episode of the Post Concussion Podcast with myself, Bella Paige, and today's guest, Dr. Gerald Komarnicky. Gerald Komarnicky holds three degrees in physics, visual science and his doctorate in optometry. He graduated from Pacific University in Oregon and he’s from his hometown in Sarnia, Ontario. He currently practices primary care of optometry in Vancouver BC. He also has participated in six FDA studies, seven other clinical studies, published 13 papers and is a professional speaker on laser eye surgery, co-management, oculomotor dysfunction as it relates to concussion injury and many other practices. He has served on 14 advisory panels and 13 roundtable forms and one US think tank for optometrists. He is a past chair of the Board of Examiners in Optometry of BC and the chair of the College of Optometrists in BC as well.
Welcome to the show, Dr. Gerald.
[00:02:03] GK: Thank you for having me, and please feel free just to call me Gerry.
[00:02:06] BP: Sounds great. So to start, do you want to tell everyone what led to your interest in helping individuals with concussion recovery?
[00:02:13] GK: Sure. I’ll answer this in three parts. The first part was, back in about 2014, I noticed that there was a greater awareness in both the public and the professions for concussion injury. I was seeking out a way to objectively measure the degree of concussion in an objective fashion. This way I could tell, is the person injured? How is the recovery coming and were they recovered? I look to something called visual evoked potentials or VEPs. What happens is, when light hits your eye, it sets up an electrical signal that passes through your brain back to the back of your head where you have visual cortex, which is where in fact you do your seeing.
When there’s this visual evoked potential, we form a wave. There’s a bottom of the wave called the trough and then the peak of the wave, which is just basically the apex and then the time it takes for that wave to occur. In a concussion injury, the peak and the trough are not altered, but the time to form the wave is slowed down. The wave is not traveling at a way that it would normally go from your eyes back to your brain. This is where some of the visual confusion is theoried come from. As people recover from their concussion, their visual evoked potential returns back to a normal state, if they return back to normal of course.
When I did that, I thought, “Okay, here I am assessing the degree of concussion, but I’m really not doing anything to help people.” VEP is helpful to the lawyers, and to the insurance companies but not to the person. Then I went back to thinking about my time at a lab back in 1982 in University. We were looking at something called oculomotor skills, that is just the way an eye moves and holds onto a target, and how this breaks down with concussion injury. I developed a tool back in those days, at least conceptually, that people could use to detect and diagnose oculomotor dysfunction. They could use it as a therapy tool to help them recover. And as their oculomotor dysfunction recovers to normalcy, the symptoms of their concussion recede. That was a way for me to help people directly do their own work at home and to supplement the care they’re getting at a concussion clinic.
Finally, the real answer is, in my office, I will see people anywhere between two weeks and two months after their concussion injury and they have to stress that they’re seeking a way to get help and get relief. I will demonstrate to them how their eyes are moving back and forth, something called saccadic eye movements. Now, they hold onto a target that has two targets separated by 40 cm straight across from their eyes. It’s like holding your fingers to the side of your head. I ask them to count aloud one second at a time looking for one target to the other. So, one, two, three, four. A healthy person can go back and forth smoothly without distress for 30 seconds. A person with a newly acquired concussion will sometimes get to four or maybe eight. They’ll drop the rod, cradle their head, start to cry or show distress and say, “Please don’t make me do this anymore, I feel sick.” When I do that, I demonstrate to them the degree of their distress and I then teach them how they can help themselves recover.
[00:05:53] BP: For sure, which is so important. It’s really hard, I find a lot of people don’t realize that they need help with their eyes until later, especially with individuals who have prolonged concussion symptoms that last for not a few months but a year or more. Then they put it together and then they’re like, “Oh my eyes need help.” And it takes some time to realize that.
[00:06:20] GK: Most people don’t recognize that 85% of the electrical activity of your brain when your eyes are open is attributed to visual processing and 23% of your brain is involved in integrating visual information. It’s no wonder people have visual distress.
[00:06:37] BP: For sure. I know lots of people have issues. I always had issues with light sensitivity so that was always my first thought that the lights hurt my eyes, but not all the movement. I know I had a lot of trouble reading and never — it took me a while to put together, because I had headaches and I never thought that it was because my eyes were not working, not because my brain was hurting.
[00:07:01] GK: Most of the time, all these symptoms are interrelated, they’re not usually in isolation.
[00:07:08] BP: No, for sure. Do you want to explain the tissues that concussion survivors often have in relation to their eyes?
[00:07:15] GK: This is something called oculomotor skills. We have three oculomotor skills. One is the way we move our eyes back and forth. That’s called the saccadic eye movement. Our ability to fixate or hold a focus on a target and our ability to focus and pursue or track a moving target. These three oculomotor skills, when you have a concussion, break down and they never break down in isolation, it’s always two or all three of all skills.
As your oculomotor function recovers, the symptoms of your concussion recover. A lot of your visual distress relates to your total distress with a concussion injury. If we can resolve the visual discomfort, you become more functional and enjoy a lifestyle free of the symptoms.
We can train you how to do eye movement skills that help you in recovery. When you start to do these exercises it’s difficult and you won’t get through the entire exercise program, which is only five minutes a day doing six eye exercises. But over time as you do them, you’ll find that you can do them more comfortably for a longer period of time without stress.
[00:08:32] BP: For sure. It’s so important to do all of those exercises and actually be diligent with it, but we’re going to talk more about how to do those exercises in a little bit. But something we had mentioned and talked previously about was doing these eye exercises incorrectly or without proper education. What are some of your concerns about that?
[00:08:58] GK: In any type of therapy, whether it’s occupational therapy, physical therapy or vision therapy, there are standardized protocols and standardized techniques that are developed over time. These are two specifically targeted muscle groups and neural centers within your brain. Just to move your eyes back and forth in a haphazardly fashion might give you some benefit, but it doesn’t give you proven benefit. What we want to do is target specific nerve centers, and nerve groups, and muscle groups in a very specific format, so that you’re getting the proven scientific benefit.
The standardization of eye movement skills is done by Northern State University College of Optometry, VOH System, DEM, [inaudible 00:09:45]. All these studies show standardized motions. For example, when you’re doing back and forth eye movement skills, lots of times a therapist will just say, “Well hold two pencils beside your eyes and look back and forth to the pencils.”
[00:10:04] BP: Yeah, like pencil pushups. I remember all those.
[00:10:07] GK: Are those pencils on plane? Is one higher than the other? Is one further from the other? When you have a visual perceptual disorder as you would have when you have a concussion injury, you won’t necessarily have them at a set distance on a correct plane. When you do that, you start to trigger different muscle groups, and different groups, and different nerve centers of your brain. That’s more confusing than keeping it down to the simple scientifically proven patterns.
For example, you have 12 major nerves that come off your brain stem called cranial nerves. Six of those go to help with visual processing. Three of them go to eye muscles. If I want you to specifically activate only one cranial nerve or two cranial nerves, then you have to do it in a specific way.
One of the most undetected and undiagnosed conditions is when the eyes actually lose focus and the ability to fuse in a vertical fashion. That’s easily overlooked by a clinician. Very few practitioners have the tools and the skills to actually measure those things and pick up what’s called the vertical deviation. That’s an entirely different nerve and muscle group that must be managed separately than just looking back and forth. Interesting stuff for a guy like me.
[00:11:29] BP: Yes, for sure. It’s interesting for me and I actually went to — I’ve gone to two concussion conferences or sports with the Academy of Neurology in the states. I went to the eye seminars and that was a lot of the talk. It’s quite interesting, but it’s definitely, some of it is way over my head.
[00:11:52] GK: Well, just to be clear, doing some exercise will not cause you harm if you do it improperly. But what you want to get is the most benefit.
[00:12:01] BP: For sure. If you’re going to spend the time doing it, I feel like doing it right is the best way.
[00:12:07] GK: Yeah, it’s kind of like building a house. Build it right the first time.
[00:12:10] BP: Yes, for sure. We have kind of touched on it, but what are your thoughts on having, there’s no governing body on concussion treatment centers. I could open one tomorrow if I wanted.
[00:12:23] GK: All professionals are guided with a self-regulatory body. This is set up to protect the public. Physicians, neurologists, optometrists, physical therapists, occupational therapists, they all belong to a provincially mandated regulatory body. It’s not federal, it’s provincial. All these professionals are held to account to a standard of practice. Regulatory bodies only act on a complaint. If the public makes a written signed complaint, then that individual practitioner would be investigated to make sure that the public is not being put at harm.
When it comes to clinics, the clinics are not regulated and there is no federal or provincial body that regulates these centers. Now, you’ll notice that some centers are accredited and they put a banner on their windows saying that they’re an accredited system. Well, I have to ask you, “Who does the accreditation?” Because it is not a government mandate. What it really is and I hate to say this, but it’s a business model. A group of people set up a clinic, they set up some training, which is good and then they share that training and give individual clinics the benefit of their training and the clinics can say they’re accredited.
Well, quite frankly, I just have to question, what is the authority of that accreditation paper? If we’re going to truly have accreditation, we need to have all stakeholders from all professions get together as a group, come together with consensus and continually review the processes that give true accreditation.
[00:14:08] BP: Yeah, no it does and I get that because I know there’s like even especially right now, concussion clinics are popping up everywhere and they all have very different ranges of education inside of them, from physical therapists, to a neurologist, to no direct specialist or just a chiropractor. There’s quite a variety of what’s inside of each concussion clinic, but they’re all considered the same thing. I think it’s a bit of an issue where we’re not having, like who’s deciding that you can treat concussions?
[00:14:47] GK: It’s a fair comment. First of all, concussion management is a business. It’s very clear that it’s a business and it’s a part of my practice. Quite frankly, I generate some revenue from helping people with concussion. It’s a fair statement, an honest statement. But managing concussion is not in isolation from one discipline to another. We all need to work together for the benefit of the patient. As we’ve already said, everybody’s concussion is different. The cause of their injury, the way their brain responds to the injury, their ability to recover, their symptoms, their level of distress, are sometimes immeasurable, but true to the person and it’s going to take multidisciplinary viewpoints and actions. No one body can do all things for all people.
[00:15:37] BP: For sure, which is what adds to the complicated nature of treating a concussion, right?
[00:15:43] GK: It’s an evolving understanding. We still don’t know what a concussion really is.
[00:15:48] BP: No, we don’t know much. But I am glad that there’s so many people popping up and researching and trying to help people with concussions because 10 years ago when I started, the comparison to what there is available now is a huge difference. It’s becoming easier to get help, which is really important. [00:16:08] GK: Some centers will say they only treat based on evidence-based treatments. I applaud that approach because that is the scientific and medical approach. But truly, because we’re all individuals and clinicians are scientists as well, that we have to work on evidenced-informed basis. The original definition of evidence-based included the judgment of the practitioner to the individual they’re facing, then that was removed.
About two years ago, the Ontario Nurses Association came out with a paper that talked about bringing back evidence-informed treatments rather than evidence-based treatments. I think they made a solid case with that.
[00:16:52] BP: Yeah, that’s interesting for sure. You can learn more about the C-Rod and at-home vision therapy tool, which we will be discussing next at concussionrecovery.net, which will also be found in today’s show notes. With, let’s take a break.
[BREAK]
[00:17:13] BP: Want to create awareness for concussions? Want to support our podcast and website? Buy awareness clothing today on postconcussioninc.com and get 10% off using LISTEN IN and be sure to tag Post Concussion Inc. in your photos. We’d love to see them.
[INTERVIEW CONTINUED]
[00:17:40] BP: Welcome back to the Post Concussion Podcast with myself, Bella Paige and today’s guest, Dr. Gerald Komarnicky. I have tried this C-Rod out for a few weeks now. Who is the C-Rod for?
[00:17:52] GK: Okay. The C-Rod is a low-cost, portable, practically indestructible tool that almost anybody can use for a multitude of purposes. What we’re talking about here today is with concussion recovery. We already know that people have visual distress with concussion and one of the primary causes of that is breakdown of oculomotor function. The C-Rod has six eye exercises and it takes five minutes a day for a healthy person to go through those exercises. When somebody has a concussion injury and they try and do the exercises, they will not get through them completely and smoothly. They have to build up time. When they start with this, we ask people to keep a diary of their progress. Let’s say in exercise number one, they can only do it for 10 seconds and then they just feel distressed, so stop. Write down the 10 seconds and the next day, maybe you’ll get to 11, maybe you’ll get to 9, maybe you’ll get to 10. But record your progress. Over time, you’re going to find, probably by three months, that you can get through the entire exercise program relatively smoothly, if not completely smoothly without distress.
As your ability to do these eye exercises improves, you’ll find your symptoms of your recovery diminish well. So I’m of the mind that as your visual oculomotor dysfunction recovers, your symptoms associated with concussion injury are reduced dramatically. Maybe not completely, but certainly reduced. Who can use this? Anybody with a concussion injury. Athletes use it, people who have reading difficulties use it. There’s even a group in Ottawa that are psychologists that are using saccadic eye movements to bring out emotional distress that people have, but that’s more off the topic.
[00:19:50] BP: Okay. How do the exercises of using C-Rod help someone who is recovering from a concussion?
[00:19:58] GK: [inaudible 0:19:58] your eye is diminished with a concussion injury, your endurance to maintain visual fusion is diminished. The ability for your eyes to focus in, turn in and rotate in and balance is diminished. All those activities are measurable and trainable. That’s proven over the last 40 years. We want to train people how they can move their eyes back and forth, at a distance of basically one foot to infinity. As you know that the ability to turn your eyes in is compromised when you’re trying to read. We could increase that strength and range of motion, the ability to move eyes back and forth without confusion, to track objects, and the speed of eye movements and basically getting back your binocular vision.
If you were to look up the definition of binocular vision symptoms for people who have binocular vision disorders, and you put that side-by-side with concussion disorders and their visual symptoms, you would find they’re practically one-to-one. Using both eyes together as a team is binocular vision and that is all enhanceable. When people regain their binocular function, their distress levels go down.
[00:21:16] BP: Okay. Interesting. Well, how long do you need to use the C-Rod to expect a benefit?
[00:21:23] GK: Most people most of the time will use it for 30 days and maybe even up to 90 days before they start to feel like they don’t need it anymore. Part of that is physiologic. When you have a concussion injury, at the cellular level it is an energy crisis. The nerve centers have gone into protective mode and shut down the metabolism of sugars. They’ve run out of energy. The nerve fibers are probably twisted, fractured, the installation around nerves is damaged. There’s a whole biochemical shutdown that takes place. That can take up to 90 days for that energy system to regain itself. While you’re doing eye exercises, you are pushing that system to get working again.
When concussions were first managed, let’s say 10 or 20 years ago, people were told to go home and rest and don’t do any activities. Now, they ask them to rest for about a week and then to take on any activities that they can in a controlled fashion. You want to engage your brain. If you don’t engage your brain, you’re going to find that you become sleepier, you’re going to think about your injury more, your lethargy will increase. You want to get moving.
[00:22:44] BP: For sure. Yeah, that’s really important. The one thing I did find was, when I was personally using the C-Rod, was how tired it made me. The first day I did it, I did it in the afternoon, like in the middle of my day, and I was done for the day. I actually went and slept for the rest of the day. Do you want to explain why this occurs?
[00:23:06] GK: Sure. Vision is a very energy expensive activity. When you’re trying to specifically ask your visual system to work when it’s injured, that’s a greater energy expense. Our energy pie is only so big and when you’re expelling energy just to keep things moving in a coordinated fashion, that robs you of the energy that you might otherwise use for recovery or for processing of what you’re looking at and reading. It doesn’t surprise me that you were fatigued. I often tell people when they use the C-Rod, do it at a time that they feel rested, and that they have time afterwards to recover from it, just as you describe.
[00:23:49] BP: Yeah. It got better. It was just the first time that wiped me out. But after I used it for weeks, I realized that I could use it at different times. But there’s the benefit of, do you do it at night before you go to bed, but your eyes are tired or do you do it in the day? Like you have to find the perfect time that works with your schedule, right?
[00:24:13] GK: Yeah. Well, it’s kind of like a swimmer. They swim for hours and hours and hours to participate in a one-minute race. It’s the same thing with eye exercises. You slowly build up over time, you push yourself but you don’t go past the point of exhaustion. You allow yourself to recover and you build on the previous day’s work.
[00:24:33] BP: For sure. Well, I personally found the C-Rod helped me — actually, the one place I noticed the most that it helped was social media. Because you’re scrolling, and picture flipping, and moving your eyes constantly while you’re on it and I spend a lot more time on it now than I ever did before I started the podcast, answering questions, responding to tagged photos, all of those kinds of things. I find I’m not getting as tired or getting a headache from being on it anymore, which is fantastic for me.
[00:25:07] GK: When you look at social media, your eyes have to converge, which means they have to turn in. The focusing system of your eyes is tied to the convergence system and there’s specific ratios of how much muscle effort it takes for those things to work as a team in a smooth, coordinated fashion. With concussion injury, all that is broken down. That’s where your distress would come from. But the more you exercise your system, the more you get back what’s called the accommodated convergence function, so that all ratios are working together so it’s less energy expensive for you to prolonged up-close work.
[00:25:45] BP: For sure, yeah. That definitely helped me. Is there anything else that you would like to add before ending today’s episode?
[00:25:53] GK: I am of the mind, as many researchers are, that concussion is a lifelong injury. The goal of therapy is for you to regain a lifestyle that’s free of distress. It doesn’t mean that injury never occurred or that you’re completely recovered. You might have emotional or behavioral changes that take place, you might have visual disturbances that linger, you might have auditory or balance issues that linger, but you do the best you can with what you have. The C-Rod was developed for people to help themselves and to supplement any clinical therapy they’re getting.
Not everybody has the financial means to go to a concussion clinic or the physical means to get there or geographic limitations. In COVID, many clinics are closed, so people need to do something to help themselves. What I recommend to everybody is take your time to recover, don’t sleep, but you need to rest. There’s no real science behind that. What we want people now to do is engage their brains, don’t deprive yourself of sleep, but don’t spend all your time sleeping. Engage, walk in fresh air, eat good food. My area of interest was oculomotor dysfunction. There’s only a little piece of the puzzle. We don’t understand concussion injury fully, but do the best you can to help yourself and understand you have to just be the best person you can be following your injury.
[00:27:19] BP: For sure. Well, thank you so much for joining and sharing all of your work and insights on concussion recovery.
[OUTRO]
[00:27:27] P: Has your life been affected by concussions? Join our podcast by getting in touch. Thank you so much for listening to the Post Concussion Podcast. Be sure to help us educate the world about the reality of concussions, by giving us a share. To learn more, don't forget to subscribe.
[END]
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